Over the past 2 years, I’ve had the privilege of working with four teams on well-evidenced health care interventions that have had a significant impact on their target groups. Although each team has managed to extend the reach of their interventions to new sites, replicating impact has proved more difficult. Together, we’ve been grappling with the question of what it takes to transition from an innovator with a proven intervention to spreading your idea and having the desired impact in adopter sites.

At the Health Foundation, we’ve been running the Exploring Social Franchising programme, with support from Spring Impact, an organisation with expertise in replicating social projects, to help these teams develop a social franchising approach to achieve their spread ambitions.

Social franchising is a mutually beneficial relationship which requires exchange between an innovator or franchisor and adopter site or franchisee (as depicted below) with the goal of replicating impact in different locations.

Our programme is very much exploratory and we don’t yet know how effective social franchising will be in the NHS, despite its common use in health care in low and middle-income countries. But we know that through the structured and systematic approach of building a social franchising model, the teams have developed their skills and processes to better enable them to spread their interventions. Having time and support to think systematically about scaling has given them space to reflect on their approach to spread and reenergise their plans. I’ve seen this happen in different ways with all four project teams.

Redesigning your organisation to achieve spread

Identification and Referral to Improve Safety (IRIS) is an evidence-based specialist domestic violence and abuse (DVA) training, support and referral programme for general practices that has been positively evaluated in a randomised controlled trial. IRISi was launched as a social enterprise in 2017 to promote and improve the health care response to gender based violence continuing to deliver the IRIS programme.

We at the Health Foundation and Spring Impact supported the small team to develop their organisational structure and think through the roles and skills required to realise their ambitions. IRISi has consequently invested in its core team, which has doubled in size to 10 staff. They have defined clear roles and responsibilities, with a specific team focused on developing their social franchise with experts in data analysis and communications (among others).

Enabling local ownership through an empowering relationship

The social franchising approach has helped teams define who should be responsible for developing and maintaining relationships with franchisees (those adopting the intervention), to balance local ownership with central support.

One of the teams developing a social franchise, the PROMPT Maternity Foundation (PMF), has developed an interesting partnership model with adopters to get this balance right. The PROMPT training package, which helps maternity care teams improve labour outcomes for mothers and babies, has been delivered across the UK and internationally. The PMF team has thoughtfully considered what type of relationship they would like with adopter sites. They will work collaboratively to provide ongoing support to adopter sites, while learning from them about their experience of local adaptation. It’s hoped this type of relationship will ensure the adopter sites have the right level of buy-in and ownership to embed PROMPT for the long term.

Identifying what makes your intervention work

Once an intervention has been implemented by an adopter site, it’s important to understand whether it is achieving the impact that the central team know is possible. So how do teams know what good looks like?

PRIMIS, a business unit within the University of Nottingham, has explored this for their intervention, PINCER, which reduces the prescription errors made by GPs, using technology and ongoing pharmacist support. The team have used their years of experience of running PINCER to determine which aspects of the intervention are essential for the desired impact.

Social franchises have clearly defined core aspects versus flexible aspects adapted locally. Defining the core has helped PRIMIS outline which aspects of the model adopter sites must adhere to in order to best implement the intervention.

Creating a powerful set of data to drive improvement

Having a network of adopter sites delivering an intervention means that data can be collected from across a variety of sites. Social franchises have quality management processes which allows the franchisor to understand how franchisees are performing and support them appropriately to maintain the required standards. Pathway, a charity supporting homeless patients to have better experiences of care, is building a social franchise for its homeless hospital team intervention. These are teams of professionals from primary care, social care and the housing sector who support people who are homeless after they have been admitted to hospital or attended A&E to have a more positive experience in hospital as well as a better discharge from hospital. As part of their model, Pathway has developed a data collection framework which all adopter sites will be expected to populate on a regular basis. This data will enable Pathway to deepen their understanding of the experience of supporting people who are homeless in hospitals. Good practice in one adopter site can be shared across the network to support improved standards which will ultimately lead to better patient experience.

The journey from innovation to spread

The process to date of developing social franchises has helped the four teams move further along in their journey from innovation to spread. The period of innovation requires agility and creativity, often with ad hoc and opportunistic development (rather than a focus on systematic approaches for internal ways of working, strategy development and engaging with stakeholders). The teams’ experience of taking stock of their core skills and developing more systematic approaches for data collection among other things seems to have put them in a stronger position to engage with adopter sites.

The social franchise models have been designed to support adopter sites not only to deliver the interventions but also to have the desired patient impact through collaborative and reflective relationships. Over the coming year and a half, we’ll see the teams recruit several adopter sites who will work with them to refine their spread models. We’re excited to see whether social franchising can support effective spread within the NHS and how the teams utilise this experience to support their organisations’ spread aims.

Daphne Amevenu (@d_amevenu) is a Programme Manager in the Improvement team at the Health Foundation.

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